本文關鍵詞：不同膀胱狀態(tài)下局部晚期宮頸癌EBRT聯合ICBT放療融合劑量學分布的比較　出處：《西南醫(yī)科大學》2017年碩士論文　論文類型：學位論文

  更多相關文章： 宮頸癌 膀胱狀態(tài) 劑量分布 放射治療 融合劑量

【摘要】：目的:宮頸癌是女性常見惡性腫瘤之一,按FIGO分期,Ⅱa期以前患者可選擇手術治療,Ⅱb期以后患者以放療為主要治療。宮頸癌放療包括外照射(external beam radiotherapy,EBRT)和腔內近距離治療(intracavitary brachytherapy,ICBT),EBRT聯合ICBT是局部晚期宮頸癌(locally advanced cervical cancer,LACC)標準放療技術,膀胱狀態(tài)是影響靶區(qū)和危及器官(organs at risk,OARs)劑量分布的常見因素。長期以來,LACC EBRT和ICBT放療靶區(qū)和危及器官(organs at risk,OARs)劑量評價分別在相應計劃中完成,缺乏綜合劑量評價依據。因此,不同膀胱狀態(tài)下,LACC EBRT聯合ICBT放療的融合劑量分布如何,不清楚。本研究主要目的通過Oncentra治療計劃系統(treatment planning system,TPS)的計劃疊加功能,比較不同膀胱狀態(tài)下,調強放射治療(intensity modulated radiotherapy,IMRT)與四野盒式照射(BOX-RT)聯合ICBT放療,靶區(qū)和OARs幾何和融合劑量分布。方法:2015-01-01~2015-07-31西南醫(yī)科大學附屬醫(yī)院腫瘤科治療的符合入選標準的LACC患者中,信封法隨機選擇20例,膀胱充盈及空虛狀態(tài)下分別行磁共振(magnetic resonance imaging,MRI)和計算機斷層成像模擬定位(simulation computed tomography,Sim-CT)掃描,在TPS對應融合MRI/CT圖像。在MRI勾畫大體腫瘤體積(gross tumor volume,GTV),Sim-CT勾畫臨床靶體積(clinical target volume,CTV)、計劃靶體積(planning target volume,PTV)和OARs(小腸,膀胱,直腸和左右股骨頭)。分別設置BOX-RT/ICBT計劃及IMRT/ICBT計劃,放射源分別為6mv-x射線和192ir。在box-rt/icbt計劃及imrt/icbt計劃中分別單獨計算各自計劃中靶區(qū)(d95%,d90%,d85%和d80%)和oars(小腸d1cc、2cc,膀胱d5%、10%、30%,直腸d1cc、2cc、5cc,股骨頭d1%)劑量,相加為幾何劑量。利用tps計劃疊加功能,分別疊加box-rt計劃與icbt計劃形成box-rt/icbt融合計劃,疊加imrt計劃與icbt計劃形成imrt/icbt融合計劃,計算靶區(qū)和oars劑量為融合劑量。比較不同膀胱狀態(tài)下,兩種外照射技術聯合icbt放療,靶區(qū)及oars幾何和融合劑量關系,并計算icbt對靶區(qū)和oars的劑量貢獻。數據符合正態(tài)分布采用配對t檢驗,否則采用符號秩和檢驗。參數檢驗的統計量設為t,非參數檢驗的統計量設為u,檢驗水準α=0.05。結果:1.box-rt/icbt計劃:膀胱空虛時,d95%(ugtv=3.92,tctv=14.59,tptv=14.76)、d90%(ugtv=3.92,tctv=16.51,tptv=16.86)、d85%(ugtv=3.92,tctv=18.24,tptv=19.54)、d80%(ugtv=3.92,tctv=16.04,tptv=17.98),靶區(qū)幾何劑量低于融合劑量;膀胱充盈時,d95%(ugtv=3.92,tctv=11.88,tptv=12.01),d90%(ugtv=3.92,tctv=13.80,tptv=13.71),d85%(ugtv=3.92,tctv=16.26,tptv=17.06),d80%(tgtv=17.50,tctv=16.68,tptv=18.46),靶區(qū)幾何劑量低于融合劑量;p值均0.001。gtv,ctv和ptv的幾何和融合劑量差異率基本相似,gtv劑量差異率小于5%,ctv和ptv大于5%;oars幾何劑量均高于融合劑量,小腸和直腸劑量差異率最明顯,均超過5%,膀胱和股骨頭劑量差異率相似,均小于5%。膀胱充盈時,oars的融合劑量最小。不同膀胱狀態(tài)下,icbt對靶區(qū)的幾何劑量貢獻率均低于融合劑量貢獻率,差異率均超過3%。icbt對靶區(qū)幾何和融合劑量貢獻率差異基本相似,對gtv的幾何及融合劑量貢獻率最高,超過49%,對ctv,ptv幾何劑量貢獻率較小,均小于10%,但融合劑量貢獻率高于幾何劑量貢獻率。膀胱空虛與充盈狀態(tài)下,icbt對oars的幾何劑量貢獻率均高于融合劑量貢獻率,小腸和直腸劑量貢獻差異率最明顯,均超過6%,膀胱和股骨頭劑量貢獻差異率基本相似。與膀胱充盈比較,膀胱空虛時,icbt對oars的幾何和融合劑量貢獻率均高于膀胱充盈。膀胱充盈時,融合劑量貢獻率最小。2.imrt/icbt計劃:膀胱空虛時,d95%(ugtv=3.92,tctv=11.28,tptv=10.79)、d90%(ugtv、ctv=3.92,uptv=3.25)、d85%(u=3.92)、d80%(u=3.92),靶區(qū)幾何劑量低于融合劑量;膀胱充盈時,d95%(ugtv,ptv=3.92,tctv=15.96),d90%(ugtv=3.81,uctv,ptv=3.92),d85%(u=3.92),d80%(ugtv=4.70,uctv,ptv=3.92),靶區(qū)幾何劑量低于融合劑量;p值均0.001。gtv劑量差異率膀胱充盈低于空虛(分別為0.17%~0.93%和0.32-1.07%),ctv和ptv與膀胱空虛相似(分別為1.10%~2.75%和1.22%~3.40%,0.98%~2.29%和0.94%~3.17%)。膀胱空虛時,oars幾何劑量(小腸d1cc,2cc、膀胱d5%,10%,30%、直腸d1cc,2cc,5cc和股骨頭d1%)高于融合劑量(u小腸=3.92,t小腸=11.59;u膀胱=3.92,3.92,3.36;u直腸=3.92,t股骨頭=4.77和6.06);膀胱充盈時,oars幾何劑量高于融合劑量(t小腸=10.27,8.84;t膀胱=10.69,11.77,4.91;u直腸=3.36,3.21,3.25),p值均0.005。膀胱d30%和直腸幾何平均劑量差均大于融合(分別為1.90gy,1.01gy,0.87gy,0.86gy和1.86gy,0.95gy,0.79gy,0.59gy)。左右股骨頭d1%分別為0.76gy、0.41gy和0.26gy、0.73gy。膀胱空虛時,icbt對靶區(qū),d95%(ugtv=3.92,tctv=11.40,tptv=10.84),d90%(ugtv=3.92,uctv=3.29,tptv=6.00),d85%(ugtv=3.92,tctv=17.29,tptv=13.87),d80%(ugtv=3.92,tctv=16.60,tptv=15.41),幾何劑量貢獻率低于融合劑量貢獻率;膀胱充盈時,icbt對靶區(qū),d95%(ugtv=9.87,uctv=15.78,uptv=10.65)、d90%(ugtv=3.81,tctv=20.70,tptv=17.64)、d85%(tgtv=8.31,tctv=23.27,tptv=19.78)、d80%(tgtv=4.68,uctv=3.92,tptv=19.90)幾何劑量貢獻率低于融合劑量貢獻率;p0.005.對gtv劑量貢獻率最高,膀胱空虛與充盈幾何及融合劑量貢獻率分別為51.12%~63.89%、48.10%~60.80%和49.52%~63.35%、46.74%~60.52%;對ctv、ptv幾何及融合劑量貢獻率10.00%。膀胱空虛時,icbt對oars的幾何劑量貢獻率高于融合劑量貢獻率(u小腸=3.92;u膀胱=3.92,3.92,3.36;u直腸=3.92;t股骨頭=4.67和6.16);膀胱充盈時,icbt對oars的幾何劑量貢獻率高于融合劑量貢獻率(t小腸=10.14,8.77;t膀胱=10.74,11.82,4.93;u直腸=3.25,3.21,3.21),p0.005.icbt對直腸幾何及融合劑量貢獻率膀胱空虛小于充盈(分別為47.77%~59.45%和40.87%~52.40%,47.82%~58.78%和41.61%~52.00%);icbt對膀胱幾何及融合劑量貢獻率膀胱空虛大于充盈(分別為27.60%~45.17%和26.04%~41.80%,23.36%~43.67%和21.89%~40.22%);小腸空虛大于充盈(分別為30.90%~36.90%和28.85%~34.79%,20.68%~25.13%和18.69%~22.88%);左右股骨頭均10%。3.兩種融合計劃的比較:在膀胱空虛狀態(tài),box-rt/icbt計劃與imrt/icbt計劃在ptv(d95%、d80%)劑量差異值有統計學意義,ptvd95%imrt/icbt融合劑量高于box-rt/icbt融合劑量,劑量差異值為3.26±1.32gy;ptvd80%box-rt/icbt融合劑量高于imrt/icbt融合劑量,劑量差異值為1.52±1.25gy。膀胱充盈狀態(tài)下,box-rt/icbt融合計劃與imrt/icbt融合計劃在ctv(d95%、d80%)、ptv(d95%、d80%)劑量差異值有統計學意義,ctvd95%及ptvd95%imrt/icbt融合劑量高于box-rt/icbt融合劑量,劑量差異值分別為1.49±1.02gy、1.51±1.18gy;ctvd80%及ptvd80%box-rt/icbt融合劑量高于imrt/icbt融合劑量,劑量差異值分別為0.95±0.83gy、1.04±0.79gy。不同膀胱狀態(tài)下,對于小腸和直腸,box-rt/icbt融合劑量值顯著高于imrt/icbt融合劑量值,差異有統計學意義(p0.05)。尤其是直腸,box-rt/icbt融合劑量與imrt/icbt融合劑量差異值均5gy.在膀胱充盈狀態(tài)下,小腸的box-rt/icbt融合劑量均高于IMRT/ICBT融合劑量,差異值均2Gy。無論是膀胱空虛還是充盈,BOX-RT/ICBT融合計劃ICBT對靶區(qū)劑量貢獻率均顯著高于IMRT/ICBT融合計劃ICBT對靶區(qū)劑量貢獻率,差異有統計學意義(P0.05),兩者對GTV的劑量貢獻率的差異率均5%,對CTV、PTV劑量貢獻率的差異率均4%。BOX-RT/ICBT融合計劃ICBT對OARs劑量貢獻率均顯著低于IMRT/ICBT融合計劃ICBT對OARs劑量貢獻率,差異有統計學意義(P0.05),兩者對腸道的劑量貢獻率的差異率均5%,對直腸劑量貢獻率的差異率均7%。結論:1.LACC外照射放療(BOX-RT和IMRT)聯合ICBT放療的融合劑量學評估優(yōu)于單純幾何評估,幾何與融合劑量評價在直腸的劑量差異率最大,但有待進一步臨床觀察。2.膀胱狀態(tài)會影響靶區(qū)和OARs劑量,單純幾何計算靶區(qū)和OARs劑量,有一定局限性,最好進行融合劑量學分析。3.在宮頸癌的放療過程中,膀胱充盈有利于OARs的保護,特別是小腸和膀胱,建議ERBT聯合ICBT時,膀胱應保持一定容量。雖然膀胱充盈狀態(tài)下降低了危及器官的受照劑量,但對危及器官相關遠期毒性的影響還需要進一步研究。4.與單純外照射放療(BOX-RT或IMRT)相比,ICBT有顯著優(yōu)勢,尤其是聯合BOX-RT照射時,ICBT治療優(yōu)勢更加明顯。與BOX-RT照射技術相比,IMRT在精確提高靶區(qū)照射劑量的同時能降低危及器官的受照劑量。
[Abstract]:Objective: cervical cancer is one of the common malignant tumors in women, according to the FIGO staging, stage II A patients before surgical treatment, patients with stage II B after radiotherapy for the treatment of cervical cancer radiotherapy. Including external irradiation (external beam radiotherapy, EBRT) and intracavitary brachytherapy (intracavitary, brachytherapy, ICBT, EBRT and ICBT) is the locally advanced cervical cancer (locally advanced cervical cancer, LACC) standard radiotherapy technology, bladder status is the target and organs at risk (organs at, risk, OARs) common factors of dose distribution. For a long time, LACC EBRT and ICBT radiotherapy and organs (organs at risk, OARs) respectively in dose assessment the corresponding plan, based on the lack of comprehensive dose evaluation. Therefore, different bladder condition, LACC EBRT combined with ICBT radiotherapy dose distribution fusion how unclear. This study mainly by Oncentra treatment plan The system (treatment planning system, TPS) the plan overlay function, comparison of different bladder condition, intensity-modulated radiation therapy (intensity modulated, radiotherapy, IMRT) and four field box (BOX-RT) combined with ICBT radiotherapy, target area and OARs geometry and fusion of dose distribution. Methods: The Affiliated Hospital of Medical College of Southwest oncology treatment with 2015-01-01~2015-07-31 the criteria of LACC patients, 20 cases were randomly selected, and empty bladder filling condition underwent magnetic resonance (magnetic resonance imaging, MRI) and computer tomography (simulation computed simulation tomography, Sim-CT scan, TPS) in the corresponding MRI/CT image fusion. In the delineation of gross tumor volume (MRI gross tumor volume. GTV), Sim-CT (clinical target delineation of clinical target volume, volume, CTV), planning target volume (planning target, volume, PTV) and OARs (small intestine, rectum and bladder. Left and right femoral head). Set BOX-RT/ICBT plan and IMRT/ICBT plan, radioactive sources were 6mv-x and 192ir. in X-ray box-rt/icbt plan and imrt/icbt plan were calculated separately for each plan in the target area (d95%, d90%, d85% and d80%) and oars (d1cc 2cc D5, small intestine, bladder%, 10%, 30%, rectal d1cc. 2cc, 5cc, d1%) dose, the femoral head is added to the geometric dose. Using the TPS program overlay function, respectively superimposed box-rt and ICBT plans to form the box-rt/icbt fusion scheme, superposition of the IMRT and ICBT plans to form the imrt/icbt fusion scheme, calculation of target area and oars dose of fusion dose. Comparison of different bladder condition, two kinds of external irradiation ICBT technology combined with radiotherapy, the target area and oars geometry and fusion dose relationship, and calculate the ICBT of the target area and the dose of oars. The contribution of data to conform to normal distribution using the paired t test, or by Wilcoxon signed rank test. Statistical parametric test The amount is t, nonparametric test statistics for u, a =0.05. level test results: 1.box-rt/icbt plan: to empty the bladder, d95% (ugtv=3.92, tctv=14.59, tptv=14.76), d90% (ugtv=3.92, tctv=16.51, tptv=16.86), d85% (ugtv=3.92, tctv=18.24, tptv= 19.54), d80% (ugtv=3.92, tctv=16.04, tptv=17.98). The target geometry dose less than fusion dose; bladder filling, d95% (ugtv=3.92, tctv=11.88, tptv=12.01), d90% (ugtv=3.92, tctv=13.80, tptv=13.71), d85% (ugtv=3.92, tctv=16.26, tptv=17.06), d80% (tgtv=17.50, tctv=16.68, tptv=18.46), the target dose is lower than the geometric fusion dose; P values were 0.001.gtv, CTV and geometry PTV and fusion dose difference was similar, GTV dose difference rate is less than 5%, CTV and PTV is greater than 5%; oars dose was higher than that of geometric fusion agent, small intestine and rectum dose rate of the most obvious differences, more than 5%, bladder and femoral head difference dose rate Like, are less than 5%. of bladder filling, oars fusion dose minimum. Different bladder condition, geometric dose to the target area of the ICBT contribution rate was lower than the fusion dose contribution rate, the difference rate of more than 3%.icbt of different target geometry and fusion dose contribution rate similar to GTV geometry and fusion dose contribution rate the highest, more than 49% of CTV, the smaller the contribution rate of PTV geometric dose was less than 10%, but the fusion rate is higher than the dose contribution of geometric dose contribution rate. Bladder empty and filled, geometric dose of oars ICBT contribution rate were higher than the fusion dose contribution rate, small intestine and rectum dose contribution rate difference was more than 6%, bladder and femoral head dose contribution difference was similar. Compared with the filling of bladder, bladder empty, geometric ICBT on oars and fusion rate were higher than the dose contribution of bladder filling. The filling of bladder, fusion dose the minimum contribution rate of.2.im Rt/icbt plan: to empty the bladder, d95% (ugtv=3.92, tctv=11.28, tptv=10.79), d90% (ugtv, ctv=3.92, uptv=3.25), d85% (u=3.92), d80% (u=3.92), the target dose is lower than the geometric fusion dose; bladder filling, d95% (ugtv, ptv=3.92, tctv=15.96), d90% (ugtv=3.81, uctv, ptv=3.92) d85%, (u=3.92), d80% (ugtv=4.70, uctv, ptv=3.92), the target dose is lower than the geometric fusion dose; P values were 0.001.gtv dose difference rate is lower than the bladder filling empty (0.17%~0.93% and 0.32-1.07%), CTV and PTV with bladder empty similar (respectively 1.10%~2.75% and 1.22%~3.40%, 0.98%~2.29% and 0.94%~3.17%) to empty the bladder. When oars dose (geometric intestinal d1cc, 2cc, d5% 10%, 30% bladder, rectum, d1cc, 2cc, 5cc and d1% was higher than that of the femoral head (U) fusion dose of =3.92 in the small intestine, the small intestine t =11.59; u =3.92,3.92,3.36 u =3.92 rectal bladder; femoral head, t =4.77 and 6.06); bladder filling, oars geometric dose above the melting The amount of mixture (t t =10.69,11.77,4.91 =10.27,8.84 in the small intestine; bladder; rectal u =3.36,3.21,3.25), P values were the average dose of 0.005. d30% bladder and rectum geometric difference fusion (respectively 1.90gy, 1.01gy, 0.87gy, 0.86gy and 1.86gy, 0.95gy, 0.79gy, 0.59gy). The left and right femur head d1% were 0.76gy, 0.41gy and 0.26gy, 0.73gy. empty bladder, ICBT in the target area, d95% (ugtv=3.92, tctv=11.40, tptv=10.84), d90% (ugtv=3.92, uctv=3.29, tptv=6.00), d85% (ugtv=3.92, tctv=17.29, tptv=13.87), d80% (ugtv=3.92, tctv=16.60, tptv=15.41), geometric dose contribution rate is lower than the fusion dose contribution rate; bladder filling, ICBT of the target area, d95% (ugtv=9.87, uctv=15.78, uptv=10.65), d90% (ugtv=3.81, tctv=20.70, tptv=17.64), d85% (tgtv=8.31, tctv=23.27, tptv=19.78), d80% (tgtv=4.68, uctv=3.92, tptv=19.90) geometric dose contribution rate is lower than the fusion dose contribution rate; the dose of GTV p0.005. The highest contribution rate, and the filling bladder empty geometry and fusion dose contribution rates were 51.12%~63.89%, 48.10%~60.80% and 49.52%~63.35%, 46.74%~60.52%; on CTV, PTV geometry and fusion dose contribution of 10.00%. to empty the bladder, ICBT geometric dose contribution to oars ratio is higher than the amount of the contribution rate of fusion agents (u u =3.92,3.92,3.36 =3.92 in the small intestine; bladder rectum; u =3.92; t =4.67; 6.16) femoral head and bladder filling, ICBT geometric dose contribution to oars ratio is higher than the fusion dose contribution rate (t t =10.74,11.82,4.93 =10.14,8.77 in the small intestine; bladder rectum; u = 3.25,3.21,3.21), p0.005.icbt of rectum geometry and fusion dose contribution rate of bladder filling is less than the empty (respectively 47.77%~59.45% and 40.87%~52.40%, and 47.82%~58.78% 41.61%~52.00%; ICBT) on bladder geometry and fusion dose contribution rate to empty the bladder filling is greater than (respectively 27.60%~45.17% and 26.04%~41.80%, 23.36%~43.67% and 2 1.89%~40.22%); void filling is greater than the small intestine (respectively 30.90%~36.90% and 28.85%~34.79%, 20.68%~25.13% and 18.69%~22.88%); more left femoral head were 10%.3. two fusion schemes: in bladder empty state, box-rt/icbt and imrt/icbt plans in PTV (d95%, d80%) dose difference was statistically significant, ptvd95%imrt/icbt fusion doses higher than box-rt/icbt fusion dose, dose the difference value was 3.26 + 1.32gy; ptvd80%box-rt/icbt fusion fusion dose more than imrt/icbt dose, dose difference value was 1.52 + 1.25gy. of bladder filling, box-rt/ ICBT fusion and imrt/icbt fusion plan plan in CTV (d95%, d80%), PTV (d95%, d80%) dose difference was statistically significant, ctvd95% dose is higher than that of box-rt/icbt and ptvd95%imrt/icbt fusion fusion dose, dose difference values were 1.49 + 1.02gy, 1.51 + 1.18gy; ctvd80% and ptvd80%box-rt/icbt fusion dose higher than IMR T/icbt fusion dose, dose difference values were 0.95 + 0.83gy, 1.04 + 0.79gy. different bladder condition for small intestine and rectum, box-rt/icbt fusion dose value was significantly higher than that of imrt/icbt fusion dose value, the difference was statistically significant (P0.05). Especially the rectum, box-rt/icbt fusion agent content and imrt/icbt values were 5gy. fusion dose differences in bladder filling under the condition of small bowel box-rt/icbt fusion dose was higher than that of IMRT/ICBT fusion 2Gy. dose, the differences were either empty or bladder filling, BOX-RT/ICBT fusion ICBT plan on target dose contribution rate was significantly higher than that of IMRT/ICBT fusion ICBT plan contribution rate on target dose, the difference was statistically significant (P0.05), the difference of GTV dose contribution the rate of rate was 5%, the difference between PTV CTV, the contribution rate of dose rate was 4%.BOX-RT/ICBT ICBT of the OARs integration plan dose contribution rate was significantly lower than that of IMRT/ICBT fusion project ICBT of OARs dose contribution rate, the difference was statistically significant (P0.05), the difference of the intestinal dose contribution rate was 5%, 7%. conclusion differences in rectal dose contribution rate: 1.LACC external irradiation (BOX-RT and IMRT) and ICBT combined with radiotherapy dosimetry fusion evaluation on simple geometric evaluation, and geometry the fusion rate maximum dose assessment dose differences in the rectum, but further clinical observation of.2. bladder can affect the target area and the dose of OARs, calculation of target volume and OARs dose of simple geometry, there are some limitations, the best fusion dose analysis.3. in radiotherapy of cervical cancer, bladder filling is conducive to the protection of OARs. Especially in the small intestine and bladder, suggest that ERBT combined with ICBT, the bladder should maintain a certain capacity. Although the bladder filling was reduced dose of the organs at risk, but also need to influence the long-term toxicity of the relevant organs The further study of.4. and simple external irradiation (BOX-RT or IMRT) compared to ICBT has significant advantages, especially when combined with BOX-RT irradiation, the advantage of ICBT treatment is more obvious. Compared with the BOX-RT irradiation technology, IMRT can improve accuracy in lower doses to organs and target doses.

【學位授予單位】：西南醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R737.33

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